Malcolm Needs

After I brought up the idea of hyperhemolysis, our medical director got with the hem-onc doc and they decidedd that is what it has to be. He is being treated with plasma exchange and I don't know what else. I hope he doesn't have another sickle crisis anytime soon. Thanks for all your input. Merry Christmas everyone.

Cliff, you are a complete STAR!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

UPDATE!!
I sent an email to and got a reply from Mark Yazer - the SCARF site is down for maintenance. Whew - I was afraid it had gone out of existance.

I spoke too soon.  I don't think I can find the smashing lights, but you now have snow!

Sorry, this new software doesn't have the smashing lights or snow.  I'm sorry.

We also only run an autocontrol when we do antibody ID.

Almost certainly hyperhaemolysis if the patient's Hb ends up lower than before the transfusion was given.
DO NOT TRANSFUSE FURTHER UNLESS THE ANAEMIA BECOMES LIFE THREATENING.
If further transfusion is needed, give high dose IVIG and methylprednisolone, and cross your fingers.
Read many papers by Win N.

No!

No!

Is anyone else missing the snow and smashable Christmas lights from last year as much as I am? 

Wow...sorry everyone; guess I have not replied to responses since this website changed and I see I made a mess of it!  Was trying to respond to people's individual posts...
Brenda

Auntie-D, one of my absolte PET hates is receiving inadequate samples on patient's with an auto-antibody, especially as the User Guide and the back of the Request Form both have printed on them the MINIMUM sample volume required.
I sometimes think that people believe we can do the impossible (or, maybe, guess our results!!!!!!).

:boogie:At least now I know why some of the e-mails I have sent were returned as undeliverable.  I'll update my address book.  Wouldn't want you to miss out on any of the wonderfully funny stuff I pass along! 

Oh I forgot the pan reactive one that they want 2 units for tomorrow for a chemo day patient. I had it all ready and packaged to go to the reference centre for them to crossmatch and this particular member of staff decides to do a 10 cell panel and enzyme too and empirically crossmatch 6 units with hope of getting 2 - all units pos, panel pan reactive. And surprise surprise there isn't enough sample left for the reference center to do it. So instead of coming in tomorrow for a transfusion the poor woman will be bled again and sent home and have to come in for a third time! Exactly the situation I wanted to avoid

Our blood center is 2 hours away, and like others have said, our biggest problem product is Platelets.  We keep some on hand, but sometimes run out and need to get shipments off schedule.  Another product difficulty is when you need to order those 'rare' antigen typed units.  How many to get is always a game.
 
Another impact is your ability to ID complex antibodies.  We rarely send anything to our reference lab, just because of the time and logistics.  So, even though we have all generalists, we are pretty good at ABID.

Hi David,
Unless they have performed thermal amplitude tests, which, of course, they may have done for all I know, I can't see that they can say it is a clinically insignificant panagglutinin. If the antibody is detectable at 30oC or above, then it is clinically significant, whatever the specificity.
In this particular case, however, I am a little worried about the specificity - not from the transfusion point-of-view - but from the patient outcome point-of-view. As the antibody/antigen reaction is destroyed by the action of proteolytic enzymes, it is unlikely to be either an auto-anti-I or an auto-anti-HI, but sounds more like an auto-anti-Pr, which, as far as I am aware, foretells a worse prognosis for the patient than does an auto-anti-I or auto-anti-HI.
Of course, from this distance, I could be talking complete rubbish!

We do this all the time Eagle Eye (something in CAT, nothing in tube and cross-match by tube) and have had NO problems whatsoever for well over a decade (and we are a Reference Laboratory). I say again, something that I have posted many times, there were no more patients killed by either AHTR or DHTR in the old days, when we only had tube techniques, than are killed now that we have all these other more sensitive techniques. The only difference is that we now detect a lot more antibodies that (theoretically) are clinically significant, but (practically) are not.

Hi Mabel,
I remember making Dolichos biflorus lectin way back in the mid 1970s at the Blood Group Reference Laboratory. It was, to say the least, bucket chemistry!
I am sure that it is done in a much more refined way these days, but, to give you some idea, this is the "recipe" from Boorman KE, Dodd BE, Lincoln PJ, Blood Group Serology, 6th edition, 1988, Churchill Livingstone.
"A 2g packet of seedsis soaked overnight in approximately 25ml of saline. The seeds are then ground, preferably in an electric grinder but a papper mill may be used. The extract is poued off, a further 25ml of saline added and the seeds reground. The process is repeated once more. The three amounts of fluid are pooled and stored at -20oC.
The ground seeds are again soaked overnight. The extraction procedure is repeated the next day until the seeds are thoroughly macerated and the volume of fluid has reached about 600ml. The process can be completed on the third day or continued over several days.
The pooled extract is filtered through several layers of gauze to remove coarse particles and frozen overnight. After thawing, it is centrifuged preferably using a high speed centrifuge, after which the supernatant is collected and frozen and thawed once more. It is examined for coarse particles which tend to come out when the extract is stored and if necessary it is refiltered and/or centrifuged to remove these. When the suspension is fine, it is standardised by testing by both tile and tube techniques at various dilutions against A1 and A2 cells.
The Dolichos extract should be used at a dilution which gives strong agglutination with A1 cells while being negative with A2.
The extract can be freeze-dried, stored and reconstituted when required. This procedure is usually unnecessary, however, as it stores very well frozen at -20oC.
It is tested with a panel of known cells of sub-groups A1 and A2 as the extract may need dilution to give clear negatives with A2 cells."
We may have come a long way from this "recipe", but my firm bet is on the reagent being the cause of your disappointment!
As a matter of interest, I have, in our walk-in fridge, a small box of Dolichos biflorus seeds that once belonged to Dr. George W Bird himself!

We would recommend giving e+, E- units.
The thing is that the "anti-e" is almost certainly a mimicking specificity (the actual specificity being something like an anti-Rh17 or anti-Rh18). The "auto-anti-e" can probably be adsorbed out to extinction with e-, E+ red cells (although it will take more adsorptions than doing it with e+, E- red cells), but this will prove that it is quite okay to give e+, E- blood, and you will not run the risk of sensitising the patient to make a genuine allo-anti-E.
There will be very rare cases when e+ transfusions will not give some form of sustainable increase in Hb (i.e. less than a week, or the patient actually has a reaction to the transfusion), when you just have to give e-, E+ units, but these cases are very, very few and far between.

Had a BMS put up a cold agglutinin screen last week (possibly a coroner's case, possibly going to court) by PBS and by DTT-treated plasma WITHOUT a control! I was livid!

I agree too - Least incompatible is like saying someone is "a little pregnant"!

I agree wholeheartedly with Joanne Croke about the "least incompatible" issue. I'm not a fan and no longer use the term here. We either give compatible units, or make our physician sign for incompatible.

Problem is, giving 'least incompatible' just makes the tech feel better.  Patient-wise, grade of compatibility doesn't always correspond to clinical significance (that's a whole 'nother conversation).
 
Knowing that, if we have a patient whose auto antibody cannot be either removed (e.g. autoabsorption or differential absorption) or circumvented by other methods (e.g. less sensitive method, prewarming, etc.) so we can see 'what is under there', then we transfuse antigen-negative for the antigens that the patient does not possess.  In other words, we avoid potential antibodies/antibody formation and we 'ignore' auto-antibodies.
 
I say 'ignore' in semi-quote because if the patient is overtly hemolyzing (not all are fulminent), then it may be best to transfuse antigen-negative for the so named auto-antibody.
 
If we had this patient ... if we can't clear away the auto-antibody, we'd give antigen 'identical'.  (Noticing comments above, give E-neg only if he/she is E-neg.)  If he/she is in an acute hemolysis situation (i.e. rapidly hemolyizing and dropping hct, severely low hct) then we'd consider giving e-neg RBCs.

I think I will get away from the venting,(although venting can be very important to ones sanity at times) because although we have a few issues (generally minor, like not checking pending logs when they are supposed to and acting on them) for the most part my techs are very responsible and really take their jobs to heart. They all really care and I am so thankful to have worked with this group for the last 12+ years. I will be retiring Jan 3 and its been a great group to work with. I will still PRN a few shifts here and there but not as manager. I will still check in on BB Talk. Will have time to visit and spoil my little grandbaby. Hopefully get to move back to New England (New Hampshire or Maine), depends on the housing market. Anyway, Merry Christmas and Happy New Year to all of you. Thanks so much for this website, it is a great thing.

We would recommend giving e+, E- units.
The thing is that the "anti-e" is almost certainly a mimicking specificity (the actual specificity being something like an anti-Rh17 or anti-Rh18). The "auto-anti-e" can probably be adsorbed out to extinction with e-, E+ red cells (although it will take more adsorptions than doing it with e+, E- red cells), but this will prove that it is quite okay to give e+, E- blood, and you will not run the risk of sensitising the patient to make a genuine allo-anti-E.
There will be very rare cases when e+ transfusions will not give some form of sustainable increase in Hb (i.e. less than a week, or the patient actually has a reaction to the transfusion), when you just have to give e-, E+ units, but these cases are very, very few and far between.